Proctitis, Proctocolitis, and Enteritis
Sexually transmitted gastrointestinal syndromes include proctitis, proctocolitis, and enteritis. Evaluation for these syndromes should include recommended diagnostic procedures, including anoscopy or sigmoidoscopy, stool examination for WBCs, and microbiologic workup (e.g., gonorrhea, chlamydia [LGV PCR if available], herpes simplex NAAT, and syphilis serology). For those with enteritis, stool culture or LGV PCR also is recommended.
Proctitis is inflammation of the rectum (i.e., the distal 10–12 cm) that can be associated with anorectal pain, tenesmus, or rectal discharge. Fecal leukocytes are common. Proctitis occurs predominantly among persons who have receptive anal exposures (oral-anal, digital-anal, or genital-anal). N. gonorrhoeae, C. trachomatis (including LGV serovars), HSV, and T. pallidum are the most common STI pathogens. Genital HSV and LGV proctitis are more prevalent among persons with HIV infection (545,556,1382). M. genitalium has been detected in certain cases of proctitis and might be more common among persons with HIV infection (937,1382). N. meningitidis has been identified as an etiology of proctitis among MSM with HIV infection (1383).
Proctocolitis is associated with symptoms of proctitis, diarrhea or abdominal cramps, and inflammation of the colonic mucosa extending to 12 cm above the anus. Fecal leukocytes might be detected on stool examination, depending on the pathogen. Proctocolitis can be acquired through receptive anal intercourse or by oral-anal contact, depending on the pathogen.
Pathogenic organisms include Campylobacter species, Shigella species, E. histolytica, LGV serovars of C. trachomatis, and T. pallidum. Among immunosuppressed persons with HIV infection, CMV or other opportunistic agents should be considered. The clinical presentation can be mistaken for inflammatory bowel disease or malignancy, resulting in a delayed diagnosis (1384,1385).
Enteritis usually results in diarrhea and abdominal cramping without signs of proctitis or proctocolitis. Fecal leukocytes might be detected on stool examination, depending on the pathogen. When outbreaks of gastrointestinal illness occur among social or sexual networks of MSM, clinicians should consider sexual transmission as a mode of spread and provide counseling accordingly. Sexual practices that can facilitate transmission of enteric pathogens include oral-anal contact or, in certain instances, direct genital-anal contact. G. lamblia is the most frequently implicated parasite, and bacterial pathogens include Shigella species, Salmonella, E. coli, Campylobacter species, and Cryptosporidium. Outbreaks of Shigella species, Campylobacter, Cryptosporidium, and microsporidiosis have been reported among MSM (259,274,1386,1387). Multiple enteric pathogens and concurrent STIs have also been reported. Among immunosuppressed persons with HIV infection, CMV or other opportunistic pathogens should be considered.
Diagnostic and Treatment Considerations for Acute Proctitis
Persons with symptoms of acute proctitis should be examined by anoscopy. A Gram-stained smear of any anorectal exudate from anoscopic or anal examination should be examined for polymorphonuclear leukocytes. All persons should be evaluated for herpes simplex (preferably by NAAT of rectal lesions), N. gonorrhoeae (NAAT or culture), C. trachomatis (NAAT), and T. pallidum (darkfield of lesion if available and serologic testing). If the C. trachomatis NAAT test is positive on a rectal swab and severe symptoms associated with LGV are present (including rectal ulcers, anal discharge, bleeding, ≥10 WBCs on Gram stain, and tenesmus), patients should be treated empirically for LGV. Molecular testing for LGV is not widely available or not FDA cleared, and results are not typically available in time for clinical decision-making. However, if available, molecular PCR testing for C. trachomatis serovars L1, L2, or L3 can be considered for confirming LGV (553).
The pathogenic role of M. genitalium in proctitis is unclear. For persons with persistent symptoms after standard treatment, providers should consider testing for M. genitalium with NAAT and treat if positive (see Mycoplasma genitalium).
Acute proctitis among persons who have anal exposure through oral, genital, or digital contact is usually sexually acquired (1382,1388). Presumptive therapy should be initiated while awaiting results of laboratory tests for persons with anorectal exudate detected on examination or polymorphonuclear leukocytes detected on a Gram-stained smear of anorectal exudate or secretions. Such therapy also should be initiated when anoscopy or Gram stain is not available and the clinical presentation is consistent with acute proctitis for persons reporting receptive anal exposures.
Ceftriaxone 500 mg* IM in a single dose
Doxycycline 100 mg orally 2 times/day for 7 days†
* For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered.
† Doxycycline course should be extended to 100 mg orally 2 times/day for 21 days in the presence of bloody discharge, perianal or mucosal ulcers, or tenesmus and a positive rectal chlamydia test.
Bloody discharge, perianal ulcers, or mucosal ulcers among persons with acute proctitis and rectal chlamydia (NAAT) should receive presumptive treatment for LGV with an extended course of doxycycline 100 mg orally 2 times/day for 3 weeks (1389,1390) (see Lymphogranuloma Venereum). If painful perianal ulcers are present or mucosal ulcers are detected on anoscopy, presumptive therapy should also include a regimen for genital herpes (see Genital Herpes).
Diagnostic and Treatment Considerations for Proctocolitis or Enteritis
Treatment for proctocolitis or enteritis should be directed to the specific enteric pathogen identified. Multiple stool examinations might be necessary for detecting Giardia, and special stool preparations are required for diagnosing cryptosporidiosis and microsporidiosis. Diagnostic and treatment recommendations for all enteric infections are beyond the scope of these guidelines. Providers should be aware of the potential for antimicrobial-resistant pathogens, particularly during outbreaks of Shigella and Campylobacter among sexual networks of MSM where increased resistance to azithromycin, fluoroquinolones, and isolates resistant to multiple antibiotics have been described (266,272,273,1391,1392).
Other Management Considerations
To minimize transmission and reinfection, patients treated for acute proctitis should be instructed to abstain from sexual intercourse until they and their partners have been treated (i.e., until completion of a 7-day regimen and symptoms have resolved). Studies have reported that behaviors that facilitate enteric pathogen transmission might be associated with acquisition of other STIs, including HIV infection. All persons with acute proctitis and concern for sexually transmitted proctocolitis or enteritis should be tested for HIV, syphilis, gonorrhea, and chlamydia (at other exposed sites). PEP should be considered for exposures that present a risk for HIV acquisition. For ongoing risk for HIV acquisition, PrEP should be considered.
Evidence-based interventions for preventing acquisition of sexually transmitted enteric pathogens are not available. However, extrapolating from general infection control practices for communicable diseases and established STI prevention practices, recommendations include avoiding contact with feces during sex, using barriers, and washing hands after handing materials that have been in contact with the anal area (i.e., barriers and sex toys) and after touching the anus or rectal area.
Follow-up should be based on specific etiology and severity of clinical symptoms. For proctitis associated with gonorrhea or chlamydia, retesting for the respective pathogen should be performed 3 months after treatment.
Management of Sex Partners
Partners who have had sexual contact with persons treated for gonorrhea or chlamydia <60 days before the onset of the persons symptoms should be evaluated, tested, and presumptively treated for the respective infection. Partners of persons with proctitis should be evaluated for any diseases diagnosed in the index partner. Sex partners should abstain from sexual contact until they and their partners are treated. No specific recommendations are available for screening or treating sex partners of persons with diagnosed sexually transmitted enteric pathogens; however, partners should seek care if symptomatic.
Drug Allergy, Intolerance, and Adverse Reactions
Allergic reactions with third-generation cephalosporins (e.g., ceftriaxone) are uncommon among persons with a history of penicillin allergy (620,631,658,896).
Persons with HIV infection and acute proctitis might present with bloody discharge, painful perianal ulcers, or mucosal ulcers and LGV and herpes proctitis are more prevalent among this population. Presumptive treatment in such cases should include a regimen for genital herpes and LGV.